1. Pelvic Health 101 Mairead Hughes Specialist Physiotherapist
The National Aspergillus Centre
Wythenshawe Hospital
Manchester University NHS Foundation Trust

2. Aims of todays talk… Introduce topics related to pelvic health
Raise awareness of assessment protocols and treatment options
Signpost patients to resources for education and self management
Improve general health and well being: important in holistic care of aspergillus related illnesses

4. Why…?
Having poor control of bodily functions quietly disempowers people by interfering with every single aspect of their lives; planning trips around rest room locations and breaks, fluid intake around planned activities or not going out at all. May is Pelvic Pain Awareness Month

5. True or False… Urinary incontinence is normal in females…
Urinary incontinence can only be fixed by surgical procedures…

6. Role of the Pelvis
Structural Support: primary role is to support the weight of the upper body when sitting and to transfer this weight to the lower limbs when standing. It serves as an attachment point for trunk and lower limb muscles, and also protects the internal pelvic organs. Excretion of waste products: urine, menstruation, faeces Reproduction and Sexual Well Being

7. The World Health Organization stated…
incontinence is a largely preventable and treatable condition
and “certainly not an inevitable consequence of ageing”
World Health Organization Calls First International Consultation on Incontinence. Press Release WHO/49, 1 July 1998. 

9. Pelvic Diaphragm Deepest Layer Function: Levator Ani Muscles
Pubococcygeus
Pubovaginalis
Puborectalis
Iliococcygeus
Coccygeus
Function:
Support the pelvis
Support the organs
Assist abdominals
Sphinteric
Sexual appreciation
Muscle Fibers
30% fast twitch
70% slow twitch
The deepest layer of muscles of the pelvic floor is the Levator Ani Muscles. These muscles act as a sling to support the pelvis and internal organs with continuous resting tone. Additionally the levator ani assist the abdominals during forced urination, expiration or any time the abdominals need assist with contracting. They assist with sphinteric closure as well. These muscle fibers consist of slow and fast twitch fibers which we will discuss more later.
The coccygeus is not part of the levator ani, but it is a deep muscle of the pelvic floor and stabilizes the sacro-iliac joint.

10. Mobility vs. Stability Pelvic floor- function
Supportive
Sphinteric
Sexual
Too much mobility-prolapse or incontinence
Too much fixation-pain
The pelvic floor needs to perform the functions as listed above. Due to the nature of the structures-layers of muscles surrounded by fascia -a balance of stability versus mobility is needed for the pelvic floor to function properly. There needs to be a certain amount of pliability allowing for urine and stool to pass, as well as stretching for reproductive functions. Additionally, there needs to be adequate muscle tone to provide stability, to support the pelvic organs, maintain continence, and prevent prolapse as well as allow for sexual appreciation. Physical therapists can address this by determining if the patient requires stretching and relaxation to assist with mobility, or strengthening and muscle reeducation to improve support and tone.

11. The Male Pelvic Floor

13. Female Pelvic Floor
Within the superficial muscle layer is made up of the superficial transverse perineal, bulbocavernosus and ischiocavernosus (see diagram).
Within the perineal membrane layer are the deep transverse perineal, compressor urethra and the sphincter urethra muscle. These muscles assist with sphincter control.
These two layers in combination with the fascia are also known as the urogential triangle.
Note the anal triangle. Within the anal triangle are two muscles: the internal sphincter and the external sphincter. The Internal sphincter may suffer trauma with childbirth. The external sphincter is voluntary.
Special attention to the perineal body. This is made up of a fibromuscular node known as the central perineal tendon. It is the insertion for the urogential triangle muscles, as well as the external anal sphincter and portions of the levator ani muscles. This is the region where an episiotomy may be performed or tears during childbirth most often occurs. This can later affect sphincter control and sensation.
In this diagram you can also see the gluteus maximus and a portion of the levator ani which is the deeper layer.

15. True or false It is normal to leak when you cough or sneeze
Only females get stress incontinence

16. Incontinence in Respiratory Conditions
hyperinflation
 BMD (osteoporosis)
infection exacerbation
kyphosis
 inflammatory markers
abnormal posture
Coughing
 muscle strength
pain
 LBM
Incontinence
autonomic control
constipation

17. Urinary Incontinence: Post Prostatectomy 99% Glina 2009, 1 year occasional 90% Peterson 2012
Stress incontinence
Urge Incontinence
Passive Incontinence
Frequency/low capacity
Nocturia
Post void retention
Post void dribble 80% Milios
Climacturia 70% Milios unpublished

18. Pelvic Floor “The Knack” (Bracing Techniques)
Brace with your pelvic floor and deep abdominal muscles when you cough, sneeze, lift or exercise
Need to master in controlled environment, cortical before anticipatory subconscious

19. Treatment Strategies-Incontinence
Stress and Urge
Scheduled voiding
Bladder retraining
Relaxation techniques
Type and amount of fluid intake
Patients benefit from being placed on a voiding schedule with gradual increase in time between voids. Initially start with schedule that patient can comfortably tolerate and gradually increase time. Goal is 3-4 hours between voids. Patient uses pelvic floor muscle contraction, relaxation and behavioral techniques to gradually achieve this goal. Also encouraged is type and amount of fluid intake, as well as dietary factors that may contribute to irritable bladder.

21. How long and how many?
To strengthen a muscle you need to find the isolated muscle then gradually fatigue a muscle
Must be individualised:
- How long can YOU hold for?
How many can YOU do?
How fast- time 10 quick lifts
At the righ time- c/sn/lift bucket

22. Urinary Incontinence Summary
Prevalence of UI is higher than ‘healthy’ population
Patients often more tolerant of UI symptoms as have significant other symptoms or functional issues
Major cause is coughing
Likely to impact on spirometry and ACT
Unlikely to ask for help
Big problem when severely affected
Reluctant to be assessed McVean 2002

23. Bowel Health

24. True or False You should chew your food 20 times before swallowing
‘Al Dente’ vegetables are the best for your digestive health
Digestion begins in the stomach

26. True or False
It is normal to have your bowels open once every three days….
It is normal to have your bowels open three times per day…

28. Good Bowel Habits
Optimal stool consistency- Ensure Adequate Fluids, movicol v metamucil
Eat sufficient Fibre **
Light pressure to initiate evacuation
Perineum drops, puborectalis relax, EAS open
Use Optimum Defecation Position- stool, knees
Very high priority for all pelvic floor conditions
KISS – balloon expulsion

30. True or False
It is normal to pass wind 10 times per day

31. Wind

32. Fight or Flight vs Rest and Digest
Over stimulation in current lifestyle vs ‘caveman days’ of fight or flight
Sit to eat and take time to rest following food, allows your body to focus on digestion

35. Relaxation, mindfulness…
Can help general well being as well as digestive and respiratory health
Mindfulness can help manage symptoms of breathlessness and panic

37. References
Schussler B, Laycock J, Norton P: Pelvic Floor Re-education: Principles and Practice, New York, Springer-Verlag, 1994
Wallace K: Female pelvic floor functions, dysfunctions, and behavioral approaches to treatment. Clinics in Sports Med, 13:2: , 1994
Gray, H : Gray’s Anatomy of the Human Body. Philadelphia, Lea & Febiger, 1918
Moore, K: Clinically Oriented Anatomy (ed 2) Baltimore, Williams & Wilkins, 1985
Wall LL, Norton PA, DeLancey JO: Practical Urogynecology. Baltimore, Williams & Wilkins, 1993
Pastore, E. A., & Katzman, W. B. (2012). Recognizing Myofascial Pelvic Pain in the Female Patient with Chronic Pelvic Pain. JOGNN: Journal Of Obstetric, Gynecologic & Neonatal Nursing, 41(5),
Gentilcore-Saulnier, E., McLean, L., Goldfinger, C., Pukall, C. F., & Chamberlain, S. (2010). Pelvic Floor Muscle Assessment Outcomes in Women With and Without Provoked Vestibulodynia and the Impact of a Physical Therapy Program. Journal Of Sexual Medicine, 7(2),
Schussler B, Laycock J, Norton P: Pelvic Floor Re-education: Principles and Practice. New York, Springer-Verlag, 1994